American Journal of Emergency Medicine xxx (2015) xxx–xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Benefits of computed tomography tractography in evaluation of anterior

abdominal stab wounds☆
Tamer Ertan, MD, Yusuf Sevim, MD ⁎, Talha Sarigoz, MD, Omer Topuz, MD, Baki Tastan, MD
Department of General Surgery, Kayseri Training and Research Hospital, Kayseri, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The study aimed to identify the presence of peritoneal penetration in management of anterior
Received 7 March 2015 abdominal stab wound by using computed tomography (CT) tractography.
Received in revised form 27 April 2015 Material and methods: Hemodynamically stabile, CT tractography-performed patients who were admitted to our
Accepted 18 May 2015 emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this
Available online xxxx
study, and all images were evaluated in terms of peritoneal penetration and possible intra-abdominal injury.
Results: In the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and
none of the patients without peritoneal penetration needed surgical treatment in their follow-up.
Conclusion: The procedure may be used for some selected cases of hemodynamically stable patient with anterior
abdominal stab wounds to abstain from local wound exploration.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction 2. Material and methods

Penetrating abdominal wounds were managed nonoperatively in
19th century resulted with high mortality and morbidity. During the
world wars and the Korean conflicts, penetrating wounds were started
to manage operatively. After that, conservative treatment for penetrating
wounds was suggested in selective cases at mid-20th century.
Although there is considerable regional variability in the type of
abdominal trauma, blunt abdominal traumas are more common than
abdominal stab wounds and among civilian people, and the vast of
penetrating traumas are stab wounds [1-3].
Patients without hemodynamic instability; evisceration; and sign of
peritonitis, impalement, blood from a nasogastric tube, or on rectal
examination may not require surgical management immediately.
These patients may be evaluated by serial physical examination, local
wound exploration, imaging procedures, diagnostic peritoneal lavage,
and laparoscopy. Computed tomography (CT) is one of the most used
noninvasive imaging procedures with the advantages in detecting
solid organ injuries, peritoneal penetration, and visceral injury. We
aimed in this study to identify the presence of peritoneal penetration
by a stab injury with tractography during CT scan for anterior abdominal
stab wounds to abstain from local wound exploration.
Hemodynamically stabile, CT tractography-performed patients who
were admitted to our emergency clinic with anterior abdominal stab
wounds between the years 2012 and 2014 were included in this
study. Anterior abdomen encompasses the space between the costal
margins to the groin creases and laterally to the anterior axillary lines.
Our exclusion criteria were gunshot wounds, hemodynamic instability
(systolic blood pressure b 90 mm Hg, hearth rate N100 beats per minute,
and hemoglobin level b10 g/dL) and unconsciousness, presence of
evisceration, acute hemorrhage, and signs of peritonitis.
The CT examinations were based on dual-section spiral CT scanner
(SOMATOM Emotion; Siemens Medical Solutions). This CT scanner
can acquire images with slice thickness from 1 to 10 mm, and images
with 1.5-mm slice thickness were used in this study. Intravenous
nonionic 60-mL contrast (iopromide, Ultravist; Bayer Schering Pharma
AG, Berlin, Germany) was injected within a 45- to 60-second acquisition
period. The site of stab wound was disinfected with 10% povidone
iodine solution (Batticon, Adeka Co, Samsun, Turkey), and injection of
50- to 75-mL contrast was performed through the wound compressively
to prevent overlapping of the surrounding tissues. All images were
evaluated with a radiologist and 2 surgeons together in terms of perito-
neal penetration and possible intra-abdominal injury.

☆ Disclosure statement: The authors report no proprietary or commercial interest in any

product mentioned or concept discussed in this article.
⁎ Corresponding author at: Kayseri Egitim ve Arastirma Hastanesi, Genel Cerrahi Klinigi,
Sanayi Mah. Ataturk Bulvari Hastane Cad No. 78, 38010 Kocasinan/Kayseri, 002F Turkey.
Tel.: +90 352 336 88 88; fax: +90 352 320 73 13.
E-mail addresses: tertan70@hotmail.com (T. Ertan), yusufsevim@gmail.com
(Y. Sevim), dr.talhasarigoz@yahoo.com (T. Sarigoz), drotopuz@yahoo.com (O. Topuz),
bakitastan@hotmail.com (B. Tastan).
3. Results
Computed tomography tractography-performed 20 patients with
anterior abdominal stab wounds were included in our study. The
mean age of the study subjects was 32.40 ± 12.22 years. Eighteen of
the patients (90%) were male. All of the stab wounds were caused by

http://dx.doi.org/10.1016/j.ajem.2015.05.018
0735-6757/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Ertan T, et al, Benefits of computed tomography tractography in evaluation of anterior abdominal stab wounds, Am J
Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.018
2 T. Ertan et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

Table other hand, a significant part of the patients who are hemodynamically
Some features of the study groups stable should be managed conservatively. From the beginning of the last
Sex century, management of anterior abdominal stab wounds is in evolu-
Male 18 (90%) tion. Until the 20th century, penetrating abdominal traumas (PAT)
Female 2 (10%) were managed conservatively with high mortality [5]. During the
Age (mean ± SD) 32.40 ± 12.22
world wars, early laparotomy was realized as lifesaving, and laparotomy
CT tractography
Positive penetration 10 (50%) was performed routinely for the treatment of PAT until 1960 [6]. Shaftan
Negative penetration 10 (50%) [5] published his article that included 180 patients with abdominal trau-
Localizations ma and 125 of the patients were managed nonoperatively without mor-
RUQ 6 (30%)
bidity and mortality leading to an approach that was later called
LUQ 6 (30%)
RLQ 3 (15%)
“selective conservatism.” In addition, diagnostic peritoneal lavage was
LLQ 3 (15%) described by Root et al [7] in 1965 for evaluating severe blunt abdomi-
Right flank 1 (5%) nal trauma. After that, selective nonoperative treatment of stab wounds
Left flank 1 (5%) has become standard in many trauma centers. It was reported that ap-
Epigastriuma 1 (5%)
proximately 50% of anterior stab wounds and 85% of posterior stab
No. of wounds
Single 16 (80%) wounds had been managed nonoperatively [8,9]. In 1989, Robin et al
Multiple 4 (20%) [10] published their study about anterior abdominal stab wounds, and
Effected organs they operated nearly half of the patients, and 28 (16.7%) of the laparot-
Mesentery 3 (23.08%)
omies were identified as negative. The surgeons should be selective for
Descending colon 2 (15.39%)
Epigastric artery 2 (15.39%)
operation because the negative laparotomy has significant associated
Liver laceration 2 (15.39%) morbidity. In a study, the incidence of negative or nontherapeutic lapa-
Othersb 4 (30.77%) rotomy was mentioned from 15% to 30%, with 41% complication rate
Abbreviations: RUQ, right upper quadrant; LUQ, left upper quadrant; RLQ, right lower [11]. The surgical exploration for all penetrating abdominal injuries
quadrant; LLQ, left lower quadrant. has been questioned in hemodynamically stable patients, with im-
a
Epigastric localization addition to left upper quadrant. provements in diagnostic strategies and the hope of minimizing nega-
b
Transverse colon, stomach, pancreas, and rectus.
tive laparotomies [4,12,13].
Local wound exploration has been used to rule out penetration of
anterior fascia. In this technique for anterior stab wounds, if the deepest
knife, and the most identified localizations for wounds were right and extend of the wound demonstrates the anterior fascia not violated, the
left upper quadrants (each of them for 6 patients, 30%), and there was patients without additional or extra-abdominal injuries may be
only 1 patient who had stab wounds at multiple quadrants, left upper discharged after appropriate wound care [14,15]. Thompson and
and epigastrium together (Table). Moore [16] identified that local wound exploration followed by diag-
Penetration was detected for 10 patients (50%), and those patients nostic peritoneal lavage when peritoneal violation was thought likely
underwent surgery (Figure A). The most effected organ was mesentery after stab wounds resulted in 8% negative laparotomy rate. Laparotomy
(3 patients, 23.08%; shown in Table). One of the patients (7.69%) had after positive local wound exploration with anterior facial penetration
only injury on rectus abdominis muscle. Furthermore, 10 patients has been reported as negative nearly 50% of the case [17]. As in our
were defined negative for peritoneal penetration by CT tractography study, tractography provides an advantage to the clinicians in evalua-
(Figure B and C), and all of the patients in this group were discharged tion of the penetration depth, and CT tractography may identify the
from emergency service. penetration of peritoneum clearly (penetration of anterior and posterior
In our study, CT tractography identified necessity of laparotomy fascia of rectus abdominis with continuity of peritoneum shown in
accurately in 90% of the patients, and none of the patients without peri- Figure B). We could identify the peritoneum nonviolated in this case, al-
toneal penetration needed surgical treatment in their follow-up. though we used CT images with 1.5-mm slice thickness. Administration
of the contrast may help the clinician evaluate the presence of penetra-
4. Discussion tion more accurately but not exactly. Local wound exploration carries
higher morbidity then less invasive methods [18,19]. Local wound ex-
Nonresponding or transiently responding hypotension, overt perito- ploration should be possible only subdiaphragmatic injuries and often
nitis, significant evisceration, and obvious signs of visceral injury such as proves difficult in patients with obesity or heavy muscle [20,21]. Explo-
hematemesis, significant bleeding from nasogastric tube, and ration of oblique tracts is hard to evaluate, and, after the exploration,
proctorrhagia are the indications of emergent laparotomy [4]. On the hemorrhage and local wound infection may be occurred.

Figure. Computed tomographic tractography scan. A, Penetration of peritoneum and presence of intra-abdominal contrast. B, Penetration of anterior and posterior fascia of rectus
abdominis with continuity of peritoneum. C, Penetration of subcutaneous tissues.

Please cite this article as: Ertan T, et al, Benefits of computed tomography tractography in evaluation of anterior abdominal stab wounds, Am J
Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.018
 T. Ertan et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Computed tomography should be used in some selected abdominal
stab wounds. In addition, CT is the most sensitive and specific imaging
procedure in assessing the injury severity to the liver and spleen [22].
Triple-contrast CT has been evaluated as a diagnostic modality in hemo-
dynamically stable patients in PAT. Oral, intravenous, and rectal con-
trasts are administered, and the hollow viscus should be well
evaluated with high accuracy [23]. In the past decade, triple-contrast
CT has become standard for evaluation of penetrating injuries.
In our study, we determined the necessity of laparotomy with high
accuracy by using CT tractography. We think that this procedure may
be used in the management of PAT instead of local wound exploration
in selective hemodynamically stable patients. By this way, we may eval-
uate the presence of violation of posterior fascia and peritoneum and
intra-abdominal structures together.
There are limited studies about stab wounds examined with CT
tractography. Bansal et al [24] reported that their study included
41 patients sustaining posterior and flank stab wound injuries and
underwent CT tractography. They mentioned the CT tractography
as a safe and effective strategy to evaluate posterior torso stab
wounds. Furthermore, Bruckner et al [25] reported their experience
of CT tractography applied 7 bullet wounded patients. All of those
patients who had negative for peritoneal penetration detected
with tractography were managed nonoperatively. The authors em-
phasized that the addition of tractography to the triple contrast CT
was a useful adjunct to simplify the management of the patient
with a tangential gunshot wound. In our study, as the other CT
tractography studies mentioned before, CT tractography helped us
avoid negative laparotomy.
5. Conclusions
The fascia of the rectus abdominis, the transversalis fascia, and the
peritoneum cannot be identified with CT directly. So, using of contrast
administered through the stab wound before CT scans seems logical to
abstain from this limitation. Furthermore, low number of patients was
a limitative factor to demonstrate statistical significance on the tech-
nique. However, this study showed us that tractography-added CT
may prevent the clinicians from negative laparotomy. Tractography
should be performed before CT scan practically without time losing.
The procedure may be used for some selected cases of hemodynamical-
ly stable patient with anterior abdominal stab wounds instead of local
wound exploration.
Acknowledgments
The authors thank Duygu Gulmez Sevim for her assistance in editing
of the language of this article.
Please cite this article as: Ertan T, et al, Benefits of computed tomography tractography in evaluation of anterior abdominal stab wounds, Am J
Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.018
3
References
[1] Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al. Changing pat-
terns in the management of penetrating abdominal trauma: the more things change,
the more they stay the same. J Trauma 2003;55:1095–108 [discussion 108–10].
[2] Gad MA, Saber A, Farrag S, Shams ME, Ellabban GM. Incidence, patterns, and factors
predicting mortality of abdominal injuries in trauma patients. N Am J Med Sci 2012;
4:129–34.
[3] Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP, Puhan MA, et al. A quarter cen-
tury experience in liver trauma: a plea for early computed tomography and conservative
management for all hemodynamically stable patients. World J Surg 2012;36:247–54.
[4] Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, et al. Practice
management guidelines for selective nonoperative management of penetrating
abdominal trauma. J Trauma 2010;68:721–33.
[5] Shaftan GW. Selective conservatism in penetrating abdominal trauma. J Trauma
1969;9:1026–8.
[6] Lee WC, Uddo Jr JF, Nance FC. Surgical judgment in the management of abdominal stab
wounds. Utilizing clinical criteria from a 10-year experience. Ann Surg 1984;199:549–54.
[7] Root HD, Hauser CW, McKinley CR, Lafave JW, Mendiola Jr RP. Diagnostic peritoneal
lavage. Surgery 1965;57:633–7.
[8] Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A
prospective study of 651 patients. Ann Surg 1987;205:129–32.
[9] Demetriades D, Rabinowitz B, Sofianos C, Charalambides D, Melissas J, Hatzitheofilou
C, et al. The management of penetrating injuries of the back. A prospective study of
230 patients. Ann Surg 1988;207:72–4.
[10] Robin AP, Andrews JR, Lange DA, Roberts RR, Moskal M, Barrett JA. Selective man-
agement of anterior abdominal stab wounds. J Trauma 1989;29:1684–9.
[11] Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of
morbidity. J Trauma 1995;38:350–6.
[12] Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Se-
lective nonoperative management of penetrating abdominal solid organ injuries.
Ann Surg 2006;244:620–8.
[13] Beekley AC, Blackbourne LH, Sebesta JA, McMullin N, Mullenix PS, Holcomb JB, et al.
Selective nonoperative management of penetrating torso injury from combat
fragmentation wounds. J Trauma 2008;64:S108–16 [discussion S16-7].
[14] Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, et al. Management
of patients with anterior abdominal stab wounds: a Western Trauma Association
multicenter trial. J Trauma 2009;66:1294–301.
[15] Biffl WL, Kaups KL, Pham TN, Rowell SE, Jurkovich GJ, Burlew CC, et al. Validating the West-
ern Trauma Association algorithm for managing patients with anterior abdominal stab
wounds: a Western Trauma Association multicenter trial. J Trauma 2011;71:1494–502.
[16] Thompson JS, Moore EE. Peritoneal lavage in the evaluation of penetrating abdomi-
nal trauma. Surg Gynecol Obstet 1981;153:861–3.
[17] Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA. A prospective ana-
lysis of diagnostic laparoscopy in trauma. Ann Surg 1993;217:557–64 [discussion 64–5].
[18] Leppaniemi A, Salo J, Haapiainen R. Complications of negative laparotomy for truncal
stab wounds. J Trauma 1995;38:54–8.
[19] Rosemurgy II AS, Albrink MH, Olson SM, Sherman H, Albertini J, Kramer R, et al. Ab-
dominal stab wound protocol: prospective study documents applicability for wide-
spread use. Am Surg 1995;61:112–6.
[20] Henneman PL. Penetrating abdominal trauma. Emerg Med Clin North Am 1989;7:647–66.
[21] Tsikitis V, Biffl WL, Majercik S, Harrington DT, Cioffi WG. Selective clinical manage-
ment of anterior abdominal stab wounds. Am J Surg 2004;188:807–12.
[22] Varin DS, Ringburg AN, van Lieshout EM, Patka P, Schipper IB. Accuracy of conven-
tional imaging of penetrating torso injuries in the trauma resuscitation room. Eur J
Emerg Med 2009;16:305–11.
[23] Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast heli-
cal CT in penetrating torso trauma: a prospective study to determine peritoneal
violation and the need for laparotomy. AJR Am J Roentgenol 2001;177:1247–56.
[24] Bansal V, Reid CM, Fortlage D, Lee J, Kobayashi L, Doucet J, et al. Determining injuries
from posterior and flank stab wounds using computed tomography tractography.
Am Surg 2014;80:403–7.
[25] Bruckner BA, Norman M, Scott BG. CT tractogram: technique for demonstrating
tangential bullet trajectories. J Trauma 2006;60:1362–3.